2.0 Analysis 2.1 Management and Vessel Operation The vessel was licensed as a pleasure craft and was operated by Ontario Place, a Province of Ontario Crown Corporation, as a utility craft/work-boat which transported both Ontario Place employees and others throughout the park. Because the vessel was licensed as a pleasure craft, it was not required to be inspected by Transport Canada Marine Safety. However, whether it was inspected or not, it was required to carry safety equipment sufficient for the number of people on board. The lack of on-board safety equipment may have been due to responsibility for the vessel's operation being shared between different departments of Ontario Place. The result of this division of responsibility was that no one department had a clear mandate to ensure that the vessel was properly maintained and equipped. As a result of the occurrence, the Marine Operations department of Ontario Place has taken over responsibility for all life-saving and safety equipment for all vessels owned and operated by Ontario Place. Individual departments operate the vessels for which they are responsible. 2.2 Safety Consciousness of Management and Crew Because the vessel had no safety equipment at all on board and there was no regime in place to ensure that there was, it is apparent that there was a lack of safety consciousness on the part of both management and the vessel's crew. The fact that the vessel operated in protected waters may have contributed to a false sense of security and to a degree of complacency. The public may also have had a false sense of security while aboard the SHOWBOAT because a provincial Crown Corporation operated the park and its vessels. The vessel's operators, who were seasonal employees, were unaware of the maximum cargo/persons which could be carried safely because no department supplied guidelines on the matter and there was no capacity plate posted on the vessel to give operators guidance. 2.3 Vessel Maintenance As the need arose over the years, modifications to the SHOWBOAT were made, usually by the Rides and Attractions section, which also carried out the vessel's maintenance. The full extent to which these modifications altered the original builder's design characteristics and stability criteria is, in general, unknown. However, one modification, the hole cut in the transom to duct air to the vessel's retrofitted generator, was a major contributing factor to the occurrence. Because the vessel did not have an assigned loadline, it could not have been overloaded, in the regulatory sense, on the day of the occurrence. However, the weight of the people and equipment on board was such that the vessel's effective freeboard aft was reduced to the point where water was free to flow at first through the hole in the modified transom and later over the transom. The bilge pumps were unable to cope with the volume of water, and the vessel slowlysank. 2.4 Vessel Construction and Ingress of Water Although controlled by the automatic bilge pumps, water was seeping into the hulls where the fibreglass was delaminating from the wood construction in the engine wells, port and starboard. The foam in each hull essentially had deteriorated over the years to such an extent that it had, unnoticed, become hygroscopic. Over time, it had absorbed an undetermined volume of water, and as it deteriorated, would progressively absorb more. The TSB Engineering Laboratory report shows various ways in which this type of foam can deteriorate after a 10- to 15-year life cycle. It is unknown if this eventuality was known or considered before or since the foam had been injected some 15 years prior to theoccurrence. The space between the upper and lower decks was common with the generator and motor well open spaces at the transom. It was sub-divided into three compartments separated by two longitudinal non-watertight bulkheads. Consequently, once water flooded over the coping and through the hole cut in the transom for the generator air duct, it quickly flooded both the generator and motor deep wells, and these compartments no longer contributed to the vessel'sbuoyancy. 2.5 Rescue of Persons The vessel heeled and sank in relatively shallow water, next to a sea wall and to a public walkway. Had the accident occurred at other locations along the vessel's projected route, the depth of water could have been greater and the location not as readily accessible to the public who, in this instance, was able to assist in the rescue. Without this assistance, swimmers and non-swimmers alike would have experienced considerable difficulty in reaching shore, hampered as they were by their gowns. As it was, the crew of the SHOWBOAT and members of the public, who had seen the events unfolding, reacted quickly and, together, rescued those on board. Other Ontario Place personnel also assisted. 2.6 Stability Overview Based on the vessel's loading condition of 23August 1995, the investigation has shown clearly that the SHOWBOAT was heavily laden. Flooding had commenced before departure at 1915 when the weight of the persons who had boarded was sufficient to load the SHOWBOAT to the point that the coping over the hole cut in the transom became submerged. Water then entered in volume through the generator air duct opening in the transom. The automatic bilge pumps would have been running continuously at full capacity. It is most likely that the operator did not hear them because of the distance between the control position and the stern and of the ambient noise made by the people on board and by the outboardmotors. When both motors failed in quick succession, the dynamic lift provided by the forward momentum of the vessel was lost and the vessel's reserve buoyancy was at a minimum. By that time, water would have been covering the partitioned 'tween-deck, and the detrimental effect of this large area of free surface water would have been significant. With little reserve buoyancy and marginal transverse stability, the vessel struck the sea wall. The sudden jarring caused the people on board to lose their footing and move quickly to starboard, and the ensuing moment caused the vessel to heel and to start capsizing. A further indication that the vessel had virtually no reserve buoyancy left at that time is that it did not return to the upright when the people on board fell into the water. After the starboard deck edge hit the bottom, the vessel settled, almost totally submerged, and upright. Whether or not the vessel had struck the sea wall, the SHOWBOAT undoubtedly soon would have sunk or capsized due to the loss of reserve buoyancy and to the effect of free surface water. 3.0 Conclusions 3.1 Findings The Ontario Place administration did not have operational procedures in place to ensure that its departments and personnel operated the SHOWBOAT safely. The uninspected SHOWBOAT, which was used to transport equipment and people, was licensed as a pleasure craft. There was no regime in place to ensure that life-saving equipment (i.e. lifejackets, personal flotation devices and lifebuoys) was available for the use of those on board the SHOWBOAT in an emergency. There was no life-saving equipment of any type on board and the vessel did not meet the regulatory requirements in that respect. No formal guidelines were established or provided to the crew to determine the maximum number of persons the vessel could carry safely. The vessel was heavily laden and had a pronounced trim by the stern on departure. The SHOWBOAT had been similarly loaded on numerous occasions in the past. No single Ontario Place department had clear responsibility to ensure that the vessel was efficiently maintained. The foam in the twin hulls had deteriorated and become hygroscopic, such that it was less effective in providing reserve buoyancy. Water was seeping into the vessel from the engine wells, port and starboard, where fibreglass was delaminating from the wooden construction. The hole cut in the transom to duct air to the vessel's retrofitted generator was the primary route by which large volumes of water ingressed. The vessel's trim by the stern submerged the engines' exhaust ports, and both enginesfailed. The vessel's construction was such that water ingressed through the common spaces at the transom to the under-deck space, creating a large area of free surface water. When the vessel struck the sea wall, the impact was such that the people on board lost their footing and moved quickly to the starboard side. The ensuing moment caused the vessel to heel heavily and the people on board fell into the water as the vessel sank. Those on board were rescued quickly because the location of the sinking was accessible, the water was relatively shallow, and the crew, the general public and other OntarioPlace personnel responded quickly to rescue them. The vessel's operator was the holder of a Toronto Harbour Operator's licence but had no formal training in emergency duties or life-saving equipment. 3.2 Causes The uninspected SHOWBOAT was heavily laden, downflooding and slowly sinking before it struck the sea wall. There was no life-saving equipment on the vessel, but all on board were rescued promptly because the vessel sank close to shore in relatively shallow water. Contributing to the accident was the absence of clearly defined responsibility for the management of safety and for maintenance, the lack of guidance to the operators regarding the weight the vessel could carry safely, and the modification to the vessel's transom through which water downflooded. 4.0 Safety Action 4.1 Action Taken 4.1.1 Buoyancy Foams for Marine Use The polyetherurethane foam found in the construction of the SHOWBOAT is commonly used as buoyancy material in small vessels. Following several tests conducted by the TSB and the National Research Council, the TSB forwarded Marine Safety Advisory No.2/96 to Transport Canada (TC) to advise of the foam's susceptibility to degradation by oxidation. Subsequently, TCissued Ship Safety Bulletin No.15/96, entitled Buoyancy Foams for Marine Use, on the application and care of polyetherurethane foam materials in the marine environment. In addition, TC Marine Safety undertook a major review of standards with respect to capacity, construction, etc., which is expected to be concluded in the fall of 1997. 4.1.2 Operation and Seaworthiness Furthermore, the TSB issued Marine Safety Advisory No.3/96 to apprise TC of several safety shortcomings with respect to the operation of the SHOWBOAT, inter alia, the safe carrying capacity, training of operating personnel, vessel structure, and the provision of life-saving equipment. Subsequently, TC imposed requirements on the owners to take remedial actions in these areas of concern. However, Ontario Place has taken the vessel out of service permanently. 4.1.3 Measures Taken by Ontario Place Since the occurrence, Ontario Place, inter alia, has had its vessels inspected by TC Marine Safety, instituted a weekly inspection regime, organized operating and emergency procedures, fitted all its vessels with capacity plates, maintained operating and maintenance logs for all its vessels, and implemented a training regime for vessel operators. In addition, sole responsibility for the marine program at Ontario Place, including the Crown Corporation's investigation of marine accidents involving its vessels, has been given to the Marine Operations department.